Demographic Factors May Impact Pain Management Referrals in SCLC/NSCLC

Factors including age, gender, and facility type may influence the likelihood of pain specialist referrals for lung cancer, suggesting a need for multidisciplinary pain management in this patient population.

Patient and disease factors played a notable role in the likelihood of issuing pain management referrals for patients with stage IV small cell lung cancer (SCLC) and non–small cell lung cancer (NSCLC), suggesting a need to inform providers of these disparities and possible implicit biases to improve quality of life, according to findings from a national registry analysis.

For patients with SCLC, those with 1 comorbidity (OR, 1.35; 95% CI, 1.26-1.45; P <.001), 2 comorbidities (OR, 1.55; 95% CI, 1.41-1.70; P <.001), or 3 or more comorbidities (OR, 1.81; 95% CI, 1.61-2.03; P <.001) were more likely to receive pain management referrals compared with those who had no comorbidities. Additionally, patients treated at urban facilities were more likely to receive referrals compared with those treated at metropolitan-located facilities (OR, 1.48; 95% CI, 1.17-1.87; P <.001).

Patients receiving chemotherapy were less likely to receive referrals compared with those who were not (OR, 0.59; 95% CI, 0.48-0.72; P <.001). Additionally, patients with 3 metastatic disease sites were the most likely to receive referrals (OR, 2.47; 95% CI, 1.76-3.45; P <.001) followed by those with 2 metastatic sites (OR, 1.48; 95% CI, 1.19-1.83; P <.001) compared with those with only 1 metastatic site.

Age, sex, insurance types, race, and ethnicity did not play a significant role in the likelihood of referrals for pain management for those with SCLC.

For those with NSCLC, patients older than 70 years received the lowest amount of pain referrals (odds ratio [OR], 0.77; 95% CI, 0.71-0.83; P <.001) followed by those aged 50 to 70 years (OR, 0.90; 95% CI, 0.84-0.96; P = .002) compared with patients younger than 50 years. Additionally, Black patients were less likely to receive pain management referrals compared with White patients (OR, 0.73; 95% CI, 0.69-0.77; P <.001).

Patients with private insurance were also less likely to receive referrals compared with uninsured patients (OR, 0.81; 95% CI, 0.75-0.88; P <.001) and patients with Medicaid or other types of governmental coverage were the most likely to receive referrals.

“Our study highlights the current gap in multidisciplinary palliative care provision for [pain management] in [lung cancer],” the study authors stated. “Education of oncology specialists on the assessment and management of pain should be implemented on a national level, with focused awareness of the crucial role of pain specialists in providing safe and effective pain relief to [patients with] stage IV [lung cancer].”

Investigators of this national registry analysis retrospectively reviewed data for patients diagnosed with de novo stage IV NSCLC or SCLC between 2004 and 2016. Investigators used bivariate analyses to compare patient sociodemographic and clinicopathological factors between 2 patient groups based on pain management referral status. Sociodemographic characteristics included age, sex, and race while clinicopathological factors included Charlson/Deyo comorbidity scores, treatment types, and number of metastatic sites.

The analysis included 565,884 patients with stage IV NSCLC and 148,584 patients with stage IV SCLC. Additionally, 3.1% of those with de novo stage IV NSCLC received pain management referrals. Referrals had increased yearly with 1.7% of those diagnosed in 2004 receiving referrals vs 4.1% of those diagnosed in 2016 (P <.001).

For those with SCLC, 2.9% received pain management referrals overall. The population also saw a significant increase in referrals over time with 1.6% of those diagnosed in 2004 receiving referrals vs 4.2% of those diagnosed in 2016 (P <.001).

Patients with NSCLC and comorbidities were increasingly more likely to be referred for to a pain specialist vs those with none whether they had 1 comorbidity (OR, 1.32; 95% CI, 1.27-1.36; P <.001), 2 comorbidities (OR, 1.38; 95% CI, 1.32-1.46; P <.001), or 3 comorbidities (OR, 1.56; 95% CI, 1.46-1.67; P <.001). Additionally, patients in urban (OR, 1.37; 95% CI, 1.31-1.42; P <.001) and rural facilities (OR, 1.45; 95% CI, 1.31-1.59; P <.001) were more likely to receive referrals.

“Ineffective [pain management] in patients with [lung cancer] remains an ongoing clinical concern, as current research has revealed that [lung cancer] pain continues to be undertreated despite the variety of pharmacological and non-pharmacological options. Practices and knowledge managing cancer pain has been documented to be inadequate amongst medical professionals, with the need for more effective interdisciplinary communication to determine appropriate therapies,” the study authors concluded.


Yaghi M, Beydoun N, Mowery K, et al. Social disparities in pain management provision in stage IV lung cancer: a national registry analysis. Medicine. 2023;102(8):e32888. doi:10.1097/MD.0000000000032888

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